In this article we take a look back at the most clinically relevant news of 2016 in the field of psychopharmacology.

In terms of new drugs, only one new molecular entity of psychiatric interest was approved (Pimavanserin, for Parkinson’s disease psychosis).

We summarize key points of two new guidelines related to the use of antipsychotics: the APA guidelines on the use of antipsychotics in dementia and the BAP guidelines on metabolic side effects of antipsychotics. The BAP guidelines on the management of bipolar disorder are also discussed here.

Indicated as replacement therapy for oral carbamazepine formulations, when oral administration is temporarily not feasible.

Buprenorphine

(Probuphine, Braeburn)

New implant for subdermal administration of buprenorphine for treatment of opioid dependence.

Methylnaltrexone

(Relistor, Valeant )

New tablet formulation for opioid-induced constipation.

New Treatment Guidelines

Use of Antipsychotics in Dementia – American Psychiatric Association

Dr. Rajesh Tampi, Professor of Psychiatry at Case Western Reserve University School of Medicine, summarizes in less than 5 minutes the key recommendations from the APA guidelines on the use of antipsychotics for the treatment of agitation or psychosis associated with dementia.

Key points:

If the risk and benefit assessment favors antipsychotic use:

Initiate at a low dose

Titrate up to the minimum effective dose as tolerated

Attempt to taper and withdraw within 4 months of treatment initiation

Haloperidol should not be used as first-line agent in the absence of delirium

Long-acting injectable antipsychotics should not be used

Unless indicated for co-ocurring chronic disorders

Bipolar Disorder – British Association for Psychopharmacology

In March 2016, the British Association for Psychopharmacology published new bipolar disorder guidelines.

The complete publication is 59 pages long, so we extracted some key points that you may find useful:

Lithium remains the most effective treatment preventing relapse and admission to hospital in bipolar I disorder (I).

Lithium prevents relapse to mania and, less effectively, depression (I). The highest dose that produces minimal adverse reactions and effects should be employed.

Concentrations below 0.6 mmol/L are potentially too low to be fully effective and adverse reactions and effects become important above 0.8 mmol/L.

Lithium reduces the risk of suicide (I).

Valproate as monotherapy has limited trial data, is somewhat less effective than lithium in the prevention of relapse.

Valproate should not usually be considered for women of child-bearing potential (I).

Carbamazepine as monotherapy is less effective than lithium, has little if any effect on relapse to depression and is liable to interfere with the metabolism of other drugs (I).

Lamotrigine is effective against depression in long-term treatment (I) and should be considered where depression is the major burden of the illness (IV).

Reference: Traditional evidence categories.

Evidence category I:

Meta-analysis of RCTs, at least one large, good-quality, RCT or replicated, smaller RCTs

Large representative population samples

Evidence category II:

Small, non-replicated RCTs, at least one controlled study without randomization or evidence from at least one other type of quasi-experimental study

There are some risks attached to metformin that require appropriate monitoring (renal function and vitamin B12) (S).

Reference – Strength of recommendation

A – Directly based on category I evidence from meta-analysis of randomised controlled trials, at least one large, good quality, randomised controlled trial or replicated, smaller, randomised controlled trials

B – Directly based on category II evidence from meta-analysis of randomised controlled trials, at least one large, good quality, randomised controlled trial or replicated, smaller, randomised controlled trials, or extrapolateda recommendation from category I evidence

C – Directly based on category III evidence from non-experimental descriptive studies, such as uncontrolled, comparative, correlation and case–control studies, or extrapolated recommendation from category I or II evidence

Safety communications

Aripiprazole: New FDA Warning on Impulse Control Risks

“The FDA is warning that compulsive or uncontrollable urges to gamble, binge eat, shop, and have sex have been reported with the use of aripiprazole. These uncontrollable urges were reported to have stopped when the medicine was discontinued or the dose was reduced. These impulse-control problems are rare, but they may result in harm to the patient and others if not recognized.

Although pathological gambling is listed as a reported side effect in the current aripiprazole drug labels, this description does not entirely reflect the nature of the impulse-control risk that we identified. In addition, we have become aware of other compulsive behaviors associated with aripiprazole, such as compulsive eating, shopping, and sexual actions. These compulsive behaviors can affect anyone who is taking the medicine.

As a result, we are adding new warnings about all of these compulsive behaviors to the drug labels and the patient Medication Guides for all aripiprazole products.”